Simultaneous ectopic pregnancy with intra-uterine gestation after in vitro fertilization and embryo transfer.

A case of combined intra-uterine and tubal ectopic pregnancy is described following in vitro fertilization and the transfer of two four-cell and one two-cell embryos. This phenomenon is known to be related to ovarian stimulation by gonadotropin therapy, and there is an increased risk with tubal disease. Techniques applied at the time of embryo transfer, the use of culture medium with 50% fetal cord serum to convey the embryos to the uterus, the catheterization method, and the position of the patient during transfer are presented. The risk of multiple pregnancies and combined intra-uterine and ectopic gestations increases with numbers of transfers and large volume of transfer medium. We would therefore recommend that after IVF-ET treatment in women with tubal disease, intensive care should be taken in the early follow-up period to rule out the possibility of ectopic pregnancy. In this case, a viable ongoing intra-uterine pregnancy was confirmed after surgery for right ampullary ectopic pregnancy. And a 2,925 g male in excellent condition was delivered by Cesarean section without complications.     

Risk factors and clinical features of recurrent ectopic pregnancy: a case control study

OBJECTIVE: To compare signs and symptoms between patients with recurrent and single ectopic pregnancies. DESIGN: Case-control study. SETTING: University medical center. PATIENT(S): Three hundred six women with single ectopic pregnancies and 61 women with recurrent ectopic pregnancies. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Risk factors, historical factors, and findings at presentation that may predispose to recurrent ectopic pregnancy. RESULT(S): The risk of recurrent ectopic pregnancy was increased with a history of surgery, history of live birth, and history of spontaneous miscarriage and not with a history of gonorrhea, chlamydia, pelvic inflammatory disease, Caesarean section, or pregnancy termination. Patients with a recurrent ectopic pregnancy had a nonsignificant trend toward higher initial hCG values. The majority of ultrasounds in both groups were nondiagnostic on presentation. The patients with recurrent ectopic pregnancy were less likely to have bleeding on initial presentation, though both groups had similar complaints of pain. CONCLUSION(S): Secondary prevention of ectopic pregnancy is problematic because of the paucity of risk factors that can be modified to diminish the odds of recurrence. Clinicians' ability to both diagnose and counsel patients at risk for recurrent ectopic pregnancy can be optimized by awareness of the clinical features of this condition.     

Endosalpingosis as a cause of chronic pelvic pain

Endosalpingosis, a condition characterized by ectopic oviduct epithelium, is diagnosed histologically by the appearance of benign ciliated and nonciliated columnar cells in an abnormal location. Endosalpingosis is typically without symptoms. Our unusual case report shows symptomatic endosalpingosis first seen with chronic pelvic pain. Various aspects of this disease will also be discussed.     

Results of microsurgical treatment of tubal infertility and early second-look laparoscopy in the post-pelvic inflammatory disease patient: implications for in vitro fertilization

Sixty-nine patients with tubal infertility secondary to pelvic inflammatory disease were surgically treated by one of three infertility surgeons, who used microsurgery for repair of the tubal pathologic condition and early second-look laparoscopy 6 to 30 days postoperatively for lysis of postoperative adhesions. No patient was included in this group whose disease was thought to have originated from endometriosis or prior abdominal surgery. The average follow-up time was 43.1 months (range 12 to 85.9). Nine patients were excluded from the analysis. Pregnancy outcome by procedure, expressed as the percentage of patients conceiving, was as follows: adhesiolysis, 69% (61% term, 8% ectopic); fimbrioplasty, 35% (25% term, 10% ectopic); salpingostomy, 30% (18% term, 12% ectopic); and cornual implantation, 60% (40% term, 20% ectopic). No added therapeutic value could be attributed to the use of early second-look laparoscopy. Given the relatively poor outcome of fimbrioplasty and salpingostomy, it may be prudent to advise patients with bilateral partial and/or total tubal occlusion against tuboplasty in favor of in vitro fertilization and embryo transfer.     

Aberrant expression of apoptosis-related molecules in endometriosis: a possible mechanism underlying the pathogenesis of endometriosis

Endometriosis, a disease affecting 3% to 10% of women of reproductive age, is characterized by the ectopic growth of endometrial tissue under the influence of estrogen. It is also becoming recognized as a condition in which ectopic endometrial cells exhibit abnormal proliferative and apoptotic regulation in response to appropriate stimuli. Apoptosis plays a critical role in maintaining tissue homeostasis and represents a normal function to eliminate excess or dysfunctional cells. Accumulated evidence suggests that, in healthy women, endometrial cells expelled during menstruation do not survive in ectopic locations because of programmed cell death, while decreased apoptosis may lead to the ectopic survival and implantation of these cells, resulting in the development of endometriosis. Both the inability of endometrial cells to transmit a "death" signal and the ability of endometrial cells to avoid cell death have been associated with increased expression of antiapoptotic factors and decreased expression of preapoptotic factors. Further investigations may elucidate the role of apoptosis-associated molecules in the pathogenesis of endometriosis. Medical treatment with apoptosis-inducing agents may be novel and promising therapeutic strategy for endometriosis.     

Scar Ectopic Pregnancy

Scar ectopic pregnancy is the rarest form of ectopic pregnancy and has been increasingly diagnosed all over the world. This is a life-threatening form of abnormal implantation of embryo within the myometrium and fibrous tissues in a previous scar on the uterus, especially following caesarean section. With the increasing rate of caesarean section, there is a substantial increase in this condition with better understanding of this disease. The early and accurate diagnosis with timely management can prevent pregnancy complications such as haemorrhage, uterine rupture and can preserve fertility.     

Ovarian stimulation with clomiphene is not a risk factor for extrauterine pregnancy]

In a retrospective cohort study of 252 patients with ectopic pregnancies the possible association between use of clomiphene citrate and the occurrence of an ectopic pregnancy was examined. Seventeen out of 252 patients had been treated with clomiphene. Epidemiologic data and animal experiments suggest, that there may be a role of clomiphene in the etiology of ectopic pregnancy. Marchbanks et al. [6] reported that patients who used clomiphene were found to have a relative risk of 10.0 for ectopic pregnancy. The analysis of our own data show an accumulation of classic risk factors as history of pelvic inflammatory disease or of microsurgery for treatment of tubal disease in the clomiphene group. The higher rate of ectopic pregnancies in patients who have been treated with clomiphene is more likely associated with the diagnosis of infertility than with the use of ovulatory-inducing agents. Clomiphene treatment is no independent risk factor in the etiology of ectopic pregnancy.     

The clinical features and incidence of concurrent intra and extra uterine pregnancies

Concurrent intra and extrauterine pregnancies have always been thought to be rare with a mean annual incidence of 1:30.000. The condition has been reported more frequently in the recent literature. If the incidence is increasing it is a serious development as the condition is often undiagnosed. The paper describes 5 patients with the condition presenting between 1976-1981 an incidence of 1:4000 deliveries. In two of these five patients the intrauterine pregnancy was diagnosed first and the ectopic pregnancy was undiagnosed until much later. The presence of intrauterine pregnancy often leads us to ignore the possibility of a concurrent extrauterine pregnancy. Considering that ectopic pregnancy may still cause maternal death, we believe that the condition has to be considered more often. Certain features may suggest the diagnosis. 1) Lack of vaginal bleeding or uterus larger than 9 week size with a proven ectopic pregnancy. 2) Presence of two corpora lutea at laparoscopy. 3) Ultrasound to diagnose an adnexal mass. 4) Failure of serum hCG to return to normal after abortion. The text also discusses the natural history of the condition and the higher incidence expected in the future with the wider use of ovulation inducing agents.     

Unrecognized spontaneous bilateral ampullary pregnancy treated by laparoscopy

We report on a 35-year-old woman with spontaneous bilateral tubal pregnancy. This is a rare and complex condition with uncertain etiology. Despite preoperative work-up that included clinical examination, serial ultrasound investigation, and serial quantitative beta human chorionic gonadotropin testing, the bilateral disease was not accurately diagnosed until laparoscopy. A bilateral laparoscopic linear salpingostomy was performed along with extraction of the conception products from both tubes. There were no intraoperative or postoperative complications, and the patient was discharged on the 1st postoperative day. Subsequent histopathology confirmed bilateral ectopic pregnancy. To avoid misdiagnosing bilateral ectopic pregnancy, we emphasize the need to combine clinical, sonographic, and laparoscopic investigation when the clinical picture is confusing.     

Infarcted ectopic spleen presenting as retroperitoneal mass

Wandering or ectopic spleen is an exceptionally rare condition. Because of the abnormally long pedicle, an ectopic spleen is prone to torsion and infarction. Patients can present with abdominal pain or an acute abdomen. The incidence is over a wide age range, but it occurs with a female predominance in the third to fifth decades. We present a case in a 26-year-old female of an infarcted ectopic spleen, initially thought to be a retroperitoneal mass on computed tomography scan, but found at surgery in the lower abdomen. The minimally invasive gynecologic surgeon needs to be aware of this entity, which may rarely be encountered.     

Gestational trophoblastic disease in ectopic pregnancy: A case series

OBJECTIVE: To describe 6 cases of gestational trophoblastic disease (GTD) in ectopic pregnancy admitted to Hospital Universitario de Caracas (HUC). STUDY DESIGN: Medical records of 6 patients admitted to the Obstetrics and Gynecology Department, HUC, from 1996 to 2004 were reviewed. They underwent surgery with a diagnosis of ectopic pregnancy, and histologic analysis revealed GTD. Clinical trends were analyzed. RESULTS: The prevalence of GTD in ectopic pregnancy was 0.16:1,000 deliveries. The mean patient age was 29 years. The preceding gestation was a term delivery in 4 and abortion in 2. The mean gestational age at admission was 8 weeks. All patients complained of abdominal pain, and 3 of them also had vaginal bleeding. Ultrasound revealed an adnexal tumor in 5 cases; this tumor and hemoperitoneum (6 cases) were the most frequent surgical findings. Histopathologic diagnosis was partial mole in 5 and choriocarcinoma in 1. Four patients were lost to follow-up. CONCLUSION: In this series the prevalence of ectopic GTD was high. The condition can mimic the usual symptoms of ectopic pregnancy, especially when a hemoperitoneum is present. It is important to apply strict histologic criteria for GTD when a sample of ectopic pregnancy is analyzed and to monitor those patients with careful human chorionic gonadotropin follow-up.     

Coexisting ectopic and intrauterine pregnancies: a case report

BACKGROUND: The simulated presence of intrauterine and extrauterine pregnancies is a rare condition. Diagnosis is difficult, accomplished on grounds of strong suspicion (as in assisted reproductive treatment cases), on the presence of predisposing factors (pathology of salpinx) or as a coincidental finding in the emergency room when a patient presents after an elective or spontaneous abortion. An intrauterine pregnancy may be discovered in a patient who presents with ectopic pregnancy. CASE: A 40-year-old multigravida was diagnosed with coexisting extrauterine and intrauterine pregnancies when she presented with a right ectopic pregnancy in the emergency room. The patient underwent partial right salpingectomy and an elective abortion. CONCLUSION: Patients who present with acute pelvic pain must be investigated for coexisting ectopic pregnancy even though they have a proven intrauterine pregnancy. Such an investigation is even more important if the patient is undergoing assisted reproductive treatment. In patients who have had spontaneous or elective abortion, especially in cases of a gestation <4 weeks, the differential diagnosis should include coexisting ectopic pregnancy. Failure to diagnose this condition can have serious consequences.     

急诊腹腔镜治疗异位妊娠58例临床分析

目的：探讨急诊状态下腹腔镜治疗异位妊娠的可行性、安全性及治疗效果。方法：58例患者均在入院后2h内完成术前准备，在气管插管全身麻醉下采用改良的三孔法置入腹腔镜器械，行输卵管切除术49例、宫角切除术2例、输卵管开窗术7例。结果：所有手术均在腹腔镜下顺利完成，平均手术时间42min，除2例出现脐部切口脂肪液化和1例急性肾功能衰竭外，余无并发症出现。结论：急诊腹腔镜治疗异位妊娠，可作为一种常规手术加以推广。     

Embarazo ectópico recurrente ipsolateral

An ectopic pregnancy is a common pathology in the first trimester, with an increasing incidence due to several factors. Ruptured ectopic pregnancy is one of the most dangerous emergencies in the obstetric patient, since this is a condition responsible for most pregnancy-related deaths in the first trimester. Any woman in fertile age with vaginal bleeding and/or abdominal pain can have an ectopic pregnancy, therefore we must always be aware of it, even more so if our patient has risk factors, such as previous tubal surgery.     

The significance of human chorionic gonadotropin in blood serum for the early diagnosis of ectopic pregnancy.

Determination of human chorionic gonadotropin (HCG) values in the serum by the radioimmunoassay technique, was performed in 23 women with suspected ectopic pregnancies. In 16 cases the values of HCG were high and the diagnosis of ectopic pregnancy was verified by laparoscopy and laparotomy. In 7 cases low HCG values were found and ectopic pregnancy was excluded. The detection of HCG in the serum was found to be an excellent tool for the early diagnosis of ectopic pregnancy, thus helping to prevent the dangerous sequelae which follow the late diagnosis of this condition.     

Background factors of ectopic pregnancy. I. Frequency distribution in a case-control study

Two hundred and five patients with ectopic pregnancy in a well-defined Swedish population were interviewed with respect to prior disease and pregnancy histories as well as various constitutional and socioeconomic factors. The results were compared with those of two control groups, i.e. 110 early pregnant women intending to continue the gestation to term as well as 101 women seeking voluntary interruption of pregnancy. The results provide evidence that several may be involved in the etiology of ectopic pregnancy, including abdominal (or pelvic) surgery, previous ectopic pregnancy and pelvic inflammatory disease. Furthermore, a history of infertility is strongly correlated to ectopic pregnancy. On the other hand, there is no evidence that uncomplicated spontaneous or induced abortion, parity or marital status are important factors.     

Ultrasound diagnosis of ectopic pregnancy

The diagnosis of tubal ectopic pregnancy should be based upon the positive visualization of an adnexal mass using transvaginal ultrasound rather than the absence of an intrauterine gestational sac. Ultrasound diagnosis earlier in the natural history of the condition has meant that more conservative treatment options can be considered and implemented in clinically stable women. Although laparoscopy traditionally is accepted as the gold standard in the diagnosis of tubal ectopic pregnancy, there is substantial evidence that transvaginal ultrasound is the diagnostic tool of choice in modern practice. In expert hands, this single noninvasive and reproducible diagnostic test correlates well with the presence of ectopic pregnancy at the time of surgery. This article discusses the use of ultrasound as a single stand-alone test in the diagnosis of tubal ectopic pregnancy.     

Tubal ectopic pregnancy: etiology and obstetric and gynecologic sequelae

This study investigated the etiologic and prognostic significance of pelvic inflammatory disease in primary and recurrent tubal pregnancies. Data from 492 patients (representing lower socioeconomic group) with tubal ectopic pregnancies seen at the Grady Memorial Hospital from January 1962 to December 1970 were compared with the characteristics of the obstetric population for the same period. The obstetric population had lower parity (2.5 in 1965 to 1.5 in 1970) and younger age (24 to 22 years old) while the study population had relatively stable parity (2.4) and age (26.9 years); this implies that occurrence of ectopic pregnancy is not random in character but can be attributed to etiologic factors, including a high incidence of asymptomatic infection (with N. gonorrhea) and pelvic inflammatory disease. Among patients who had tubal ectopic pregnancies, 61% conceived and 38% had at least one conception resulting in a viable infant; 39% remained infertile. 27% of repeat ectopic pregnancies were observed among patients who had initial ectopic pregnancies. Further research on the epidemiologic and etiologic factors of ectopic pregnancies will aid the physician in deciding the choice of operative procedure (salpingo-oophorectomy vs. salpingectomy) for patients with initial ectopic pregnancies.     

异位葡萄胎的诊断与治疗--附三例病例报告

目的：探讨异位葡萄胎的诊断和治疗,方法：回顾性分析我院收治的3例异位葡萄胎患者的临床资料。结果：异位葡萄胎患者的临床表现根据异位的部位不同表现各异,异位葡萄胎早期易发生局部浸润和远处转移,数字减影血管造影术,彩色多普勒超声,腹腔镜等检查在异位葡萄胎的诊断中具有重要作用,规范的化学治疗及耐药病灶的手术切除仍为其主要治疗手段,结论：异位葡萄胎患者应强调预防性化学治疗的重要性,并重视发生转移后的及时诊断与治疗。     

Clinical value of pregnancy-specific beta 1-glycoprotein (SP1) and beta-hCG determination in serum in suspected ectopic pregnancy

We compared the clinical value of pregnancy-specific beta 1-glycoprotein (SP1) determination in serum by means of a highly sensitive enzyme-linked immunosorbent assay (ELISA) versus that of beta human chorionic gonadotropin (beta-hCG) determination in suspected ectopic pregnancy. The study comprised 58 women admitted consecutively with suspected ectopic pregnancy but without signs warranting immediate surgical intervention. Both SP1 and beta-hCG were found in 11 patients with ectopic pregnancy and in 8 patients with early intra-uterine pregnancy, whereas beta-hCG was detected in 4 and SP1 in 7 of 8 women with a recent abortion. Of 31 women presenting a non-pregnant condition, 2 were positive for both SP1 and beta-hCG. The measurement of SP1 in serum thus appears to be an alternative to beta-hCG measurement when ectopic pregnancy is suspected.